Parenteral Nutrition Policy - Doncaster and Bassetlaw ... · parenteral nutrition or home...

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Parenteral Nutrition Policy This is a new procedural document, please read in full

Did you print this document yourself? The Trust discourages the retention of hard copies of policies and can only guarantee that the policy on the Trust website is the most up-to-date version. If, for exceptional reasons, you need to print a policy off, it is only valid for 24 hours.

Author/reviewer: (this version)

Dr Jo Sayer - Consultant Gastroenterologist,

Hannah Stirland - Nutrition Nurse Specialist,

Chioma Nnamdi – Specialist Pharmacist,

Andrew Gregory – Specialist Dietician

Date written/revised: February 2016

Approved by: Nutrition Steering Committee

Date of approval: 31/03/2016

Date issued: 12 April 2016

Next review date: February 2019

Target audience: Clinical Staff, Trust wide

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Amendment Form

Please record brief details of the changes made alongside the next version number. If the procedural document has been reviewed without change, this information will still need to be recorded although the version number will remain the same.

Version

Date Issued

Brief Summary of Changes

Author

Version 1

12 April 2016

This is a new procedural document, please read in full

J Sayer H Stirland C Nnamdi A Gregory

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Contents

Section

Page No.

1 Introduction 4

2 Purpose 4

3

Duties and Responsibilities

3.1 Nutrition support team

3.2 Ward medical and nursing teams

4

4

5

4

Procedure

4.1 Indication for parenteral nutrition (PN)

4.2 Referral process

4.3 Requirements for referral

4.4 Appropriate route

4.5 Prescribing pabrinex

4.6 Ward inpatients requiring PN

4.7 Patients on critical care requiring PN

4.8 Stopping parenteral nutrition

4.9 Patients on home PN who require hospitalisation

5

6

6

7

7

7

8

9

9

10

5

Training/Support

5.1 Pharmaceutical stability

5.2 The prescription

5.3 Management of PN

11

11

11

11

6 Monitoring Compliance with the Procedural Document 12

7 Definitions 12

8 Equality Impact Assessment 13

9 Associated Trust Procedural Documents 13

10 References 13

Appendices

Appendix 1 Parenteral nutrition pathway of care 14

Appendix 2 Specimen home PN transcription 16

Appendix 3 Equality Impact Assessment Form 17

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1. INTRODUCTION

The aim of this policy is to ensure parenteral nutrition (PN) is delivered to appropriate inpatients safely and in line with NICE guidance (2006). PN is a specialised treatment which carries significant risks to patients, for this reason correct delivery and management of the PN is essential. This policy outlines the indications for PN, how to refer to the nutrition support team and how to manage a patient receiving parenteral nutrition. The nutrition support team is a multidisciplinary team which consists of a consultant gastroenterologist, nutrition nurse specialist, pharmacist and dietitian. The team assess and monitor all patients receiving PN and provide support to ward nursing and medical staff in the safe delivery of parenteral nutrition.

2. PURPOSE

Parenteral Nutrition (PN) is a method of feeding patients intravenously when the patient is unable to absorb enough nutrients from the gut to meet their nutritional needs. It may be used as the sole form of nutrition or it may be combined with other forms of feeding (oral or enteral). It may be required to address specific nutritional deficiencies, for example patients with high output fistula or to meet all nutritional requirements. PN is an expensive option. It also carries a significant risk of adverse events or complications from the delivery of nutrients via an unnatural route, some of which may be serious or even fatal. Therefore it is important for patient safety and for effective treatment that this resource should be used only for those patients where the benefit outweighs the risk.

3. DUTIES AND RESPONSIBILITIES

3.1 Nutrition support team

The nutrition support team provides support for decision-making when considering starting a patient on parenteral nutrition. While the final decision regarding starting the parenteral nutrition rests with the consultant managing that patient, the nutrition support team will make recommendations regarding the most appropriate, safest and most cost effective way to meet the patient’s nutritional requirements. The nutrition support team will assess all adults on inpatient wards who have been referred for consideration of parenteral nutrition.

The nutrition support team will be informed by the pharmacist covering DCC of all adult inpatients on DCC/ITU being considered for parenteral nutrition; however where the patient is under the care of an intensivist and another consultant the decision whether to start PN will be made by the intensivist and the consultant managing the patient

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The nutrition support team will agree nutritional targets with the referring medical team and will advise how these nutritional targets can be achieved. For most referrals this will include a prescription of parenteral nutrition.

The Nutrition Support team will provide an initial assessment of the patient’s nutritional needs and how these can be met. They will monitor on a daily basis (Monday to Friday) the impact of the nutritional treatment and will be responsible for the prescription of parenteral nutrition on a seven day/week basis. Where it is necessary to prescribe other treatments in order to minimize harm from the parenteral nutrition (e.g. prescription of insulin for a patient with persistently raised blood glucose on parenteral nutrition), the nutrition support team will take responsibility for prescribing these medications, provided that there is no or low impact on the ongoing management of the patient’s medical condition. If there is concern that the new treatment may impact on the patient’s other medical problems, the nutrition support team will make a recommendation and it will be the responsibility of the medical team managing the patient to decide whether to prescribe the treatment.

3.2 Ward medical and nursing teams

The ward medical team will be responsible for ensuring that all baseline and monitoring blood tests have been obtained (see section 4.3), that the patient has appropriate vascular access for delivery of parenteral nutrition and that the patient understands the proposed treatment and the risks associated with it. Please refer to central venous access device (CVAD) policy. The medical team also has a responsibility for reviewing and overseeing the fluid balance needs of the patient. If the patient just requires maintenance fluids, then the PN will often deliver an appropriate amount of fluids to meet the patient’s needs. If this is the case then any additional fluid should be stopped. If the patient has a fluid deficit or on-going fluid losses, then additional fluids may be needed on top of the PN. The medical team has a responsibility for assessing the patient’s fluid status and requirements on a daily basis and ensuring that these are met and not exceeded by a combination of PN and intravenous fluids as appropriate. The volume of fluid delivered in the PN needs to be factored into these calculations. The ward nursing team will be responsible for monitoring the patient and ensuring that all appropriate observations have been documented; including 4 hourly clinical observations, at least daily blood sugar, twice weekly weight, accurate fluid balance and food chart if applicable. They will also be responsible for daily monitoring of the CVC and for collecting specimens e.g. swabs from CVC entry sites.

4. PROCEDURE

All patients should have a ‘MUST’ score before making a referral to the nutrition support team or a dietitian. Once referred the patient must have a dietitian review as part of the nutrition support team’s assessment. The only exception to this is patients in a critical care bed (DCC/ITU) where the consultant intensivist may choose to initiate parenteral nutrition over a weekend. It is not appropriate to start parenteral nutrition over a weekend unless the patient is in a critical care bed.

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PN should never be started in the evenings or weekends unless the expertise is available to assess and monitor the patient adequately, hence the only area where this should happen is on critical care and only if the clinical condition of the patient deems this necessary prior to a full dietician assessment.

4.1 Indications for parenteral nutrition (PN)

Parenteral nutrition is a treatment with a significant risk of complications. It should only be considered as a treatment for nutritional support after all oral and enteral options have been explored. The main indications for parenteral nutrition are:

Intestinal perforation which is being managed conservatively (non-operatively) and where feeding the patient orally may exacerbate sepsis

Intestinal obstruction which is being managed conservatively (non-operatively)

Intestinal dysmotility, including prolonged post- operative ileus and intestinal pseudo-obstruction leading to malabsorption

Acute pancreatitis where oral, nasogastric or nasojejunal feeding is not tolerated

High output stoma or high output fistula where the surgical consultant has recommended a trial period of Nil by mouth

Short bowel syndrome where absorption is not sufficient to meet patient’s nutritional targets

There may be other cases which would benefit from parenteral nutrition. These should be discussed on an individual case basis with the nutrition support team. The decision to start parenteral nutrition needs to take account of the patient’s co-morbidities, life expectancy and quality of life. For patients who are being considered for long term parenteral nutrition or home parenteral nutrition, the patient’s social and psychological state should also be considered, as well as the patient’s wishes.

4.2 Referral process

The decision to initiate a referral for parenteral nutrition must involve the consultant managing the patient and this must be documented in the medical notes. The referral must then be completed using the online system and by bleeping the nutrition support team on bleep 1812. An email to a member of the nutrition support team from the referring consultant will also be accepted. The nutrition support team can be contacted by bleep (Monday to Friday 8.00 to 16.00).

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The following: should be documented in the medical notes at the time of referral:

Medical condition leading to gut failure and leading to need for parenteral nutrition

Purpose of the parenteral nutrition ( to meet nutritional targets or to prevent further nutritional losses)

Whether the parenteral nutrition will be sole form of feeding or combined with enteral or oral feeding

Intended stopping point e.g. when patient is able to meet nutritional targets orally or enterally, or a time limited trial for example patient with high output stoma., to be nil by mouth for 2 weeks

If this information is not available the nutrition support team will see and assess the patient but the PN will not be ordered from the Pharmacy until the above criteria have been agreed between the nutrition support team and the team managing the patient.

4.3 Requirements for referral

The ward team should ensure that the following have been put in place:

Up to date ‘MUST’ score

Up to date baseline bloods. As a minimum these include: o U+E, Ca, phosphate, magnesium, glucose, LFT, FBC and clotting- o Further blood testing may then be requested by the nutrition support team.

Central venous access (usually PICC line) requested on ICE

Patient monitoring for strict fluid balance and twice weekly weight, at least BD blood glucose monitoring even if not diabetic

Patients at risk of re-feeding syndrome started on Pabrinex.

4.4 Appropriate Route

The most common route for PN administration is via a dedicated peripherally inserted central catheter (PICC). Other central vein catheterisation via the subclavian or jugular veins may be used for patients on DCC where appropriate. For long term PN, a tunnelled central venous catheter is most appropriate. Peripheral access may be used after due consideration by the nutrition support team if PN is considered for short term (<5 days). Only a limited number of PN bags are appropriate for peripheral administration and this would be documented on the prescription and on the product.

4.5 Prescribing Pabrinex

Pabrinex is an Intravenous preparation of water soluble vitamins including high dose thiamine, to reduce risk of thiamine deficiency syndromes e.g. Wernicke’s for patients at risk of re-feeding syndrome.

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All at risk patients who are starting parenteral nutrition should be prescribed Pabrinex to reduce the risk of neurological complications of re-feeding syndrome, such as Wernicke’s encephalopathy. Pabrinex should be prescribed using the TPN plus pabrinex (one pair daily for 10 days) option on JAC. If the patient has been admitted with alcohol related problems they should always be prescribed the alcohol regime on JAC. The nutrition support team will decide if pabrinex needs to be continued as part of their full assessment.

4.6 Ward inpatients requiring PN

Location of adult inpatients requiring parenteral nutrition Wards managing adult patients with parenteral nutrition must be able to ensure:

1. Sufficient trained nursing staff with up to date certification for management of central venous catheters so that there will be at least 1 trained member of staff certified competent to manage the feeding line on for each shift, to set up and take down the parenteral nutrition

2. All nursing staff including healthcare assistants are familiar with the monitoring and documentation required for managing patients on parenteral nutrition. This monitoring is detailed in the Parenteral Nutrition Pathway of Care (see appendix 1).

3. Fridge with sufficient capacity to store parenteral nutrition bags 4. Means to weigh patients including access to hoist weighing scales 5. Daily medical review of patients by consultant or middle grade doctor including

Saturday and Sunday. The following wards/areas have been designated for managing adult patients who require parenteral nutrition: DCC Doncaster ITU Bassetlaw Ward A5 Bassetlaw Ward 18 Doncaster Ward 20 Doncaster Ward 21 Doncaster Ward 24 Doncaster Ward S11 Doncaster If a patient who is not on one of these wards requires parenteral nutrition, the parenteral nutrition will not be ordered until the patient has been transferred to one of these wards. For patients with other complex medical needs, these will need to be discussed with either the nutrition support team or with one of the consultant intensivists (e.g. intra-dialysis parenteral nutrition). If due to complex needs it is not possible to transfer to one of these wards escalate to clinical lead /matron who will need to ensure appropriate support given to ward to allow safe administration.

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Any adult patient who is on home parenteral nutrition who requires hospital admission must be admitted to one of the wards designated above. Please discuss with the site manager and nutrition support team to ensure the patient is admitted to the correct ward. Once the medical team managing the patient and the nutrition support team have agreed to start a patient on parenteral nutrition, the nutrition support team will be responsible for prescribing the parenteral nutrition. They will review the patient daily (Monday to Friday) and all patients receiving parenteral nutrition will be discussed at the weekly nutrition support team MDT meeting. The nutrition support team will review the patient’s fluid and electrolyte balance and blood glucose control and make recommendations to the team managing the patient. Where it is deemed to be in the patient’s best interests, the team may prescribe fluids or other medication relating to the nutritional care of the patient. The medical team managing the patient will be responsible for ensuring timely insertion of a central catheter for feeding, prescribing of additional intravenous fluids where appropriate and collection of bloods and other samples to monitor the patient for complications of the parenteral nutrition. The medical team will follow the guidance set out in the Parenteral Nutrition Pathway of Care (appendix 1). The ward nursing team managing the patient will be responsible for monitoring the patient’s observations including blood glucose and fluid balance, as set out in the Parenteral Nutrition Pathway of Care. The ward nursing team will also be responsible for dressing the skin site of entry of the feeding line and watching for evidence of catheter related sepsis.

4.7 Patients on critical care requiring PN

Adult patients on DCC will be managed by the consultant intensivists, ward pharmacist and ward dietician. Decisions to start and stop parenteral nutrition while the patient remains on DCC will not involve the nutrition support team. The nutrition nurse (or another member of the nutrition support team) will be made aware of all adult patients on the critical care unit who are requiring parenteral nutrition and will be responsible for ensuring that the nutrition support team review the patient once they are transferred to level 2 or level 1 care. Once the patient has been transferred off DCC, the nutrition support team will be responsible for prescribing and stopping parenteral nutrition.

4.8 Stopping parenteral nutrition

For patients who are not in a critical care bed, the nutrition support team will make the decision when to stop the parenteral nutrition. In most instances this will follow a discussion between the medical team caring for the patient and the nutrition support team.

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4.9 Patients on home PN who require hospitalisation

Home parenteral nutrition patients must be admitted to one of the wards designated for parenteral nutrition. The designated wards are:

DCC Doncaster ITU Bassetlaw A5 Bassetlaw Ward 18 Doncaster Ward 20 Doncaster Ward 21 Doncaster Ward 24 Doncaster

Ward S11 Doncaster If the patient has complex medical needs that cannot be met on one of the designated wards the patient must be discussed with the nutrition support team (bleep 1812) or with a consultant intensivist. The nutrition support team MUST be informed if a home parenteral nutrition patient is admitted to Doncaster and Bassetlaw Hospitals. The team should be informed on the day of admission or on the next working day (bleep 1812). The nutrition nurse or another member of the nutrition support team will contact the Intestinal Failure centre responsible for the nutritional care of the home parenteral nutrition patient to discuss their nutritional management while the patient is in hospital. This may include transfer to the Intestinal Failure centre, where the admission is related to a complication of the parenteral nutrition. Unless advised otherwise by the Intestinal Failure centre, the patient will be managed according to the Trust Parenteral Nutrition Pathway of Care. The patient will be reviewed on a daily basis by the Nutrition support team (Monday to Friday) and will be discussed at the Nutrition team MDT meeting. The patients are required to bring their home PN bags on admission and the NST will transcribe their prescription onto the Trust PN prescription forms during working hours. If the patients are admitted out-of- hours or over the weekend, the on-call doctor covering the respective ward should complete the transcription. Transcription involves getting the home PN bag for the day and copying out the name, constituents, electrolytes and trace elements as indicated on the label and then adding the batch number and expiry dates. See specimen in appendix 1. The PN prescription forms are stocked on the appropriate wards including ward 20, 21, 24, DCC and ITU. The nutrition support team will be responsible for contacting the Intestinal Failure Unit to inform them of the patient’s discharge from hospital, within 24 hours of discharge.

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5. TRAINING/SUPPORT

The members of the nutrition support team have a responsibility to provide education and training to the medical, nursing and allied health professionals caring for the patient regarding nutritional issues and in particular with reference to safe delivery and monitoring of parenteral nutrition. All nurses delivering PN via a central line must complete the central venous access device (CVAD) package and training provided by clinical skills. Revalidation of these skills will also be provided by clinical skills and nurses must be updated at least every three years.

5.1 Pharmaceutical Stability

A ready to use bag of PN (with additives) has got a 7-day shelf life if stored between 2-80C. Once allowed to reach room temperature on the wards and in medicine preparation areas, the expiry is reduced to 24hours. Once PN is hung for administration any left-over product should be discarded after 24hours. If the patient has got additional IV fluids or medication, they should be given via a separate lumen or peripheral cannula as admixtures of PN and certain medication could result in instability of the formulation.

5.2 The Prescription

Prescriptions will be completed by the NST after patient review on a daily basis and will be based upon a comprehensive patient assessment. The prescription will detail the type of bag, any additives, rate of infusion and the route of administration.

5.3 Management of PN

All adult patients receiving parenteral nutrition within the Trust will be managed according to the guidance in the Parenteral Nutrition Pathway of Care The nutrition support team will be responsible for reviewing the pathway of care on an annual basis and ensuring that this recommends best practice and follows national and local guidance. They will consult with other interested parties such as consultant intensivists so that the guidance will be applicable for all adult patients.

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6. MONITORING COMPLIANCE WITH THE PROCEDURAL DOCUMENT

What is being Monitored

Who will carry out

the Monitoring

How often

How Reviewed/

Where Reported to

The procedural document will be reviewed in the following circumstances:

Nutrition Support Team

Every three years routinely, unless: • New national or international guidance are received. • Newly published evidence demonstrates need for change to current practice. • Action required from Root Cause Analysis Serious Incident Investigation report

Nutrition steering committee

Audits on the usage of PN

Nutrition Support Team

Every 6 months Clinical leads,

7. DEFINITIONS

NST – Nutrition Support Team ‘MUST’ – malnutrition universal screening tool PN – parenteral nutrition DCC – Department of critical care ITU - Intensive care unit CVAD- Central venous access device CVC - central venous catheter U+E – Urea and electrolyte Ca – Calcium LFT – Liver function test FBC – Full blood count

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8. EQUALITY IMPACT ASSESSMENT

An Equality Impact Assessment (EIA) has been conducted on this procedural document in line with the principles of the Equality Analysis Policy (CORP/EMP 27) and the Fair Treatment For All Policy (CORP/EMP 4).

The purpose of the EIA is to minimise and if possible remove any disproportionate impact on employees on the grounds of race, sex, disability, age, sexual orientation or religious belief. No detriment was identified. (see Appendix 3).

9. ASSOCIATED TRUST PROCEDURAL DOCUMENTS

Central Venous Access Device (CVADs) Care and Management Policy - PAT/T 23 Mental Capacity Act 2005 Policy and Guidance, including Deprivation of Liberty Safeguards (DoLS) - PAT/PA 19 Privacy and Dignity Policy - PAT/PA 28

10. REFERENCES

Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition (2006) NICE clinical guideline 32 .

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APPENDIX 1 – PARENTERAL NUTRITION PATHWAY OF CARE

- Request further bloods*

- Strict fluid balance

- Regular weights

Refer to ward Dietitian for review

Order PN Bloods

(FBC, U+E, LFT, Mg, bone*, Glucose, clotting)

Refer (NST) Online referral and Bleep 1812

Contact Site manager

NST on BLEEP 1812 J Sayer (Medical)

T Wilson (Surgical)

Parenteral nutrition pathway of care

* Or use TPN blood profile on ICE

Is PN indicated? 1

N

N

Request PICC (Complete request on ICE

and liaise with DSA)

Call NST

Is the patient on an appropriate ward?

Does patient have central access?

Has NST reviewed patient?

Assess fluid and electrolyte needs

8

7

Y

Done

4

N

N

Done Y

Y

Referral to NST MUST be authorised by the Consultant managing

the patient

2

Y

3

9

PLEASE SEE EXPLANATORY

NOTES OVERLEAF

Correct abnormal K, Mg or PO

4 before PN

Prescribe Pabrinex

Abnormal K, Mg, PO4?

(Must be checked before PN)

Is there a risk of re-feeding?

6

Y

Y

5

N

Done N

Done

10

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10

High risk of re-feeding problems if: One or more of the following:

BMI less than 16 kg/m2 Unintentional weight loss >15% within last

3-6 months Little or no nutritional intake for more

than 10 days Low levels of potassium, phosphate or

magnesium prior to feeding

Two or more of the following: BMI less than 18.5 kg/m2

Unintentional weight loss >10% within the last 3-6 months

Little or no nutritional intake for more than 5 days

A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

Pabrinex Information All patients who are starting parenteral nutrition should be prescribed Pabrinex to reduce the risk of neurological complications of re-feeding syndrome, such as Wernicke’s encephalopathy

Prescribe on JAC using the TPN plus Pabrinex option (one pair daily for ten days) Unless the patient has been admitted with alcohol related issues in which case prescribe the alcohol regimen of Pabrinex on JAC.

The following wards have been designated for managing adult patients who require parenteral nutrition: DCC Doncaster Ward 18 Doncaster Ward 20 Doncaster Ward 24 Doncaster Ward 21 Doncaster Ward S11 Doncaster Ward A5 Bassetlaw ITU Bassetlaw

Indication for Parenteral Nutrition: Parenteral nutrition is a treatment with a high risk of complications. It should only be considered as a treatment for nutritional support after all oral and enteral options have been explored. The main indications for parenteral nutrition are:

• Intestinal perforation

• Intestinal obstruction

• Intestinal dysmotility, including prolonged post- operative ileus and intestinal pseudo-obstruction leading to malabsorption

• Acute pancreatitis where nasojejunal feeding is not tolerated

• High output stoma or high output fistula where the surgical consultant has recommended a trial period of Nil by mouth

• Short bowel syndrome where absorption is not sufficient to meet patient’s nutritional targets There may be other cases who would benefit from parenteral nutrition. These should be discussed on an individual case basis with the nutrition support team.

Nursing care for all PN patients: Accurate fluid balance Blood sugar monitoring at least daily CVAD care sheet Twice weekly weight

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APPENDIX 2 – SPECIMEN HOME PN TRANSCRIPTION

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APPENDIX 3 - EQUALITY IMPACT ASSESSMENT PART 1 INITIAL SCREENING

Service/Function/Policy/

Project/Strategy Care Group/Executive Directorate and

Department Assessor (s) New or Existing

Service or Policy? Date of Assessment

Parenteral Nutrition Emergency care group Hannah Stirland New 30/03/2016

1) Who is responsible for this policy? Emergency care group

2) Describe the purpose of the service / function / policy / project/ strategy? Patients receiving parenteral nutrition (PN) and staff administering PN

3) Are there any associated objectives? NICE guidance (2006)

4) What factors contribute or detract from achieving intended outcomes? –

5) Does the policy have an impact in terms of age, race, disability, gender, gender reassignment, sexual orientation, marriage/civil partnership, maternity/pregnancy and religion/belief? No

If yes, please describe current or planned activities to address the impact [e.g. Monitoring, consultation] –

6) Is there any scope for new measures which would promote equality? [any actions to be taken]

7) Are any of the following groups adversely affected by the policy?

Protected Characteristics Affected? Impact

a) Age no

b) Disability no

c) Gender no

d) Gender Reassignment no

e) Marriage/Civil Partnership no

f) Maternity/Pregnancy no

g) Race no

h) Religion/Belief no

i) Sexual Orientation no

8) Provide the Equality Rating of the service / function /policy / project / strategy – tick outcome box

Outcome 1 Outcome 2 Outcome 3 Outcome 4

Date for next review: February 2019

Checked by: Hannah Stirland Date: 30.03.2016

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